**7. Postoperative rehabilitation following flexor tendon repair**

The surgeon must not only be aware of how to repair a lacerated flexor tendon but must also have an understanding of the postoperative rehabilitation regimen before consenting a patient for surgery. Failure to comply with rehabilitation may result in poor patient outcomes despite meticulous repair technique. Unfortunately, the best rehabilitation regimen remains to be elucidated. This is further convoluted by a paucity of well-designed randomised control trials with a Cochrane Collaboration analysis [37] being withdrawn in 2010 for being out of date and the most recent systematic review concluding that there is weak evidence supporting both early active motion protocols and combination protocols [38]. Therefore, it is imperative that the surgeon be aware of both current rehabilitation regimens as well as future directions. Current postoperative protocols for patients with flexor tendon injuries are immobilisation, early passive mobilisation and early active mobilisation [39] (**Figure 1**).

#### **7.1. Immobilisation**

**6. Repair principles and techniques**

by a large body of research data [14]. These are:

**V.** Minimal interference with tendon vascularity

and aid in the organisation of said deposition

**VIII.** Equal tension across all suture strands

**I.** Core sutures easily placed in tendon

remodelling [14].

28 Essentials of Hand Surgery

**II.** Secure knots

**III.** Smooth junctions **IV.** Minimal gapping

epitendinous sutures.

should not be repaired [34].

The ideal method of flexor tendon repair should allow a healing response precisely at the tendon ends but not between the tendon and its surroundings, creates a repair site with minimal bulk and low friction, and places enough force across the repair to promote motion and

The characteristics of an ideal tendon repair were described by Strickland [31] and confirmed

**VI.** Sufficient strength throughout healing to permit application of early motion stress.

**VII.** Motion at the repair site to increase the amount of collagen deposited at the site of injury

Strength of the repair immediately post operatively is reliant on the suture and is therefore entirely responsible for the stability in early motion stress. Ideally, the suture material used should have high tensile strength, be inextensible, cause no tissue reaction and be easy to handle and knot [31]. Flexor tendon repairs consist of two parts. The core sutures and the

Core sutures provide strength to the tendon repair. A 3/0 or 4/0 non-absorbable braided or monofilament suture are optimal for use as core suture [32]. The number of core sutures in the repair and the size of the suture is proportional to the strength of the repair. However, increasing the number of suture strands within the repair leads to increased bulk of the repair. Another factor in determining strength of the tendon repair is the grip of the core sutures. Increasing the grip of the core suture prevents the suture from pulling out of the tendon after repair [32]. The epitendinous sutures ensure smoothness of gliding and also increases the tensile strength

Large gaps in the tendon repair prevents healing with Gelberman et al. demonstrating that

Other factors include minimal handling to reduce adhesions and to avoid vascular interference to the repaired tendon [33]. Tendon lacerations less than 60% of the tendon diameter

There are many techniques available for repairing the tendon and these have been described in detail elsewhere [35]. Four-strand techniques are generally recognised to be superior to

of the repair. A locked running suture also reduces the rate of gap formation [32].

3 mm is the maximum permissible gap to allow tendon healing [33].

Immobilisation may seem counterintuitive considering the plethora of studies showing the benefits of early mobilisation on the repair strength, tenocyte healing and formation of adhesions [14, 40–44]. However, there are certain situations in which immobilisation is preferable. These include patients who [39]:


O'Connell et al. followed 78 children (under the age of 16) for 24 months and found no benefits in early mobilisation protocols in children when compared to immobilisation [45]. However, immobilisation for more than four weeks resulted in functional deterioration of the repaired tendon [45]. Kato et al. found it difficult to encourage early active motion protocols in children aged less than six and found immobilisation for three to four weeks did not increase the incidence of tendon rupture or decrease function [46].

For the non-compliant adult patient, the protocol of Cifaldi, Collins and Schwarze may be used [39, 47]. It involves three to four weeks of immobilisation in a forearm-based dorsal splint or cast (20° wrist flexion, metacarpophalangeal (MP) joints in 50° flexion and the interphalangeal (IP) joints in full extension) followed by a weaning program (it may also be used in children) [47]. Weaning involves modifying the splint so that the wrist is in neutral and instructing the patient to remove the splint every hour and passively flexing

active extension exercises with the use of a wristband. A rubber band is attached from the tip of the finger to the wristband, providing passive flexion and active extension. During this time, the patient also performs blocking and FDS gliding exercises. The late stage begins 8 weeks

Flexor Tendon Injuries

31

http://dx.doi.org/10.5772/intechopen.73392

The Kleinert protocol uses a dorsal plaster splint immediately following surgery. This splint blocks the wrist and MP articulations in flexion. The wrist is placed at approximately 45° of flexion, and the MP joints rest at approximately 20° of flexion in the initial postoperative splint. The IP joints rest in neutral alignment in this initial splint. One week following surgery, the splint is replaced with a thermoplastic splint that maintains the same angles of flexion as the initial postoperative splint. The new splint allows for passive flexion of the digits and active extension of the digits against dynamic traction using rubber bands to facilitate the traction mechanism. The bands are placed on the volar aspect of the splint and directed toward the distal nail plate from just proximal to the wrist. Early passive ROM exercises are started within the confines of the dorsal splint. At one month following the patients remove the splint and began active flexion and extension exercises. However, patients wear the dorsal splint during periods of inactivity. About six weeks after the surgical repair, the dorsal splint is discontinued, and blocking exercises are started. Two months following the repair, resistive exercises are incorporated. Patients resume normal activities approximately three months following the surgical procedure. Problems that have arisen with the Kleinert protocol include flexion contractures of the PIP joint [50]. Treatment of contractures has consisted of continued intermittent splinting with the IP joints in neutral position [51]. In recent years, rubber band traction has been almost completely abandoned, largely because of the problems arising from the flexed resting position of the PIP joint [52]Continuous passive motion (CPM) uses devices that allow for joints to move through a predetermined arc of motion [39]. The aim is to increase the duration and repetition of exercises. Gelberman et al. [53] performed a randomised control comparing traditional early passive motion to CPM exercises and demonstrated that, at 6 months, the CPM group had significantly greater range of motion. However further research in evaluating the CPM

An Early active mobilisation (EAM) protocol refers to active contraction of the repaired muscles [54, 55]. EAM promotes formation of large diameter fibrils and demonstrates the greatest cellular response to injury [48]. There are many different EAM regimens with some using a hinged dorsal blocking splint to assist with wrist synergistic motion whereas others use place and hold or active flexion [56, 57]. A well-known protocol is that by Gratton [58] who com-

• At postoperative day two to five, a thermoplastic dorsal blocking splint is fashioned with the wrist positioned in 20° of flexion and the MCP joints in 80° of flexion with the IP joints in full extension. If the patient has significant oedema, the active ROM exercises are de-

bined the Belfast and Sheffield practices [54]. The protocol is as follows:

layed until day five. Oedema is treated with compression and elevation.

postoperatively. Progressive strength building is encouraged.

following flexor tendon repair is lacking.

**7.3. Early active mobilisation**

**Figure 1.** Summary of post-operative rehabilitation protocols.

and extending the injured digit for ten repetitions. Splint wear is then discontinued at six weeks (if flexion contractures of the wrist or fingers exist at this stage, a nocturnal volar splint holding the fingers in maximal comfortable extension may be worn). At this time differential FDS and FDP gliding exercises are performed every hour for ten repetitions. To isolate FDP gliding, both the MP and proximal interphalangeal (PIP) joints are held in extension, and the patient flexes the distal interphalangeal (DIP) joint. During this manoeuvre, the FDS tendon glide is prevented. The FDS tendon is isolated by holding all fingers in extension while the patient actively flexes the PIP joint of the affected finger. By holding the fingers in extension, the common muscle belly of the FDP is held to its full length, preventing it from assisting in flexion. At 8 weeks following surgery, sustained grip activities are added to the regimen. The resistance of these activities is gradually increased over the next four weeks. Heavy resistive exercises are avoided before 12 weeks because of the risk of tendon rupture.

#### **7.2. Early passive mobilisation**

Early passive mobilisation protocols are known to inhibit adhesion formation, promote intrinsic healing, and produce a stronger repair [42–44, 47–49]. Two well-known early passive mobilisation protocols are the Duran and Houser and the Kleinert protocols [39].

In the Duran and Houser protocol, the postoperative dorsal blocking splint holds the MP joints at 50° of flexion and the wrist at 20° of flexion. These investigators showed that three to five mm of tendon excursion was necessary to prevent firm tendon adhesions. The following regimen is followed twice daily. Using the opposite hand, the PIP and the DIP joints are brought from full flexion to full extension, with eight repetitions for each joint. Then, the patient performs eight repetitions of composite MP, PIP, and DIP flexion. This protocol continues through the fourth postoperative week. Approximately 5 weeks following surgery, the patients begin active extension exercises with the use of a wristband. A rubber band is attached from the tip of the finger to the wristband, providing passive flexion and active extension. During this time, the patient also performs blocking and FDS gliding exercises. The late stage begins 8 weeks postoperatively. Progressive strength building is encouraged.

The Kleinert protocol uses a dorsal plaster splint immediately following surgery. This splint blocks the wrist and MP articulations in flexion. The wrist is placed at approximately 45° of flexion, and the MP joints rest at approximately 20° of flexion in the initial postoperative splint. The IP joints rest in neutral alignment in this initial splint. One week following surgery, the splint is replaced with a thermoplastic splint that maintains the same angles of flexion as the initial postoperative splint. The new splint allows for passive flexion of the digits and active extension of the digits against dynamic traction using rubber bands to facilitate the traction mechanism. The bands are placed on the volar aspect of the splint and directed toward the distal nail plate from just proximal to the wrist. Early passive ROM exercises are started within the confines of the dorsal splint. At one month following the patients remove the splint and began active flexion and extension exercises. However, patients wear the dorsal splint during periods of inactivity. About six weeks after the surgical repair, the dorsal splint is discontinued, and blocking exercises are started. Two months following the repair, resistive exercises are incorporated. Patients resume normal activities approximately three months following the surgical procedure. Problems that have arisen with the Kleinert protocol include flexion contractures of the PIP joint [50]. Treatment of contractures has consisted of continued intermittent splinting with the IP joints in neutral position [51]. In recent years, rubber band traction has been almost completely abandoned, largely because of the problems arising from the flexed resting position of the PIP joint [52]Continuous passive motion (CPM) uses devices that allow for joints to move through a predetermined arc of motion [39]. The aim is to increase the duration and repetition of exercises. Gelberman et al. [53] performed a randomised control comparing traditional early passive motion to CPM exercises and demonstrated that, at 6 months, the CPM group had significantly greater range of motion. However further research in evaluating the CPM following flexor tendon repair is lacking.

#### **7.3. Early active mobilisation**

and extending the injured digit for ten repetitions. Splint wear is then discontinued at six weeks (if flexion contractures of the wrist or fingers exist at this stage, a nocturnal volar splint holding the fingers in maximal comfortable extension may be worn). At this time differential FDS and FDP gliding exercises are performed every hour for ten repetitions. To isolate FDP gliding, both the MP and proximal interphalangeal (PIP) joints are held in extension, and the patient flexes the distal interphalangeal (DIP) joint. During this manoeuvre, the FDS tendon glide is prevented. The FDS tendon is isolated by holding all fingers in extension while the patient actively flexes the PIP joint of the affected finger. By holding the fingers in extension, the common muscle belly of the FDP is held to its full length, preventing it from assisting in flexion. At 8 weeks following surgery, sustained grip activities are added to the regimen. The resistance of these activities is gradually increased over the next four weeks. Heavy resistive exercises are avoided before 12 weeks because of the risk

Early passive mobilisation protocols are known to inhibit adhesion formation, promote intrinsic healing, and produce a stronger repair [42–44, 47–49]. Two well-known early passive

In the Duran and Houser protocol, the postoperative dorsal blocking splint holds the MP joints at 50° of flexion and the wrist at 20° of flexion. These investigators showed that three to five mm of tendon excursion was necessary to prevent firm tendon adhesions. The following regimen is followed twice daily. Using the opposite hand, the PIP and the DIP joints are brought from full flexion to full extension, with eight repetitions for each joint. Then, the patient performs eight repetitions of composite MP, PIP, and DIP flexion. This protocol continues through the fourth postoperative week. Approximately 5 weeks following surgery, the patients begin

mobilisation protocols are the Duran and Houser and the Kleinert protocols [39].

of tendon rupture.

30 Essentials of Hand Surgery

**7.2. Early passive mobilisation**

**Figure 1.** Summary of post-operative rehabilitation protocols.

An Early active mobilisation (EAM) protocol refers to active contraction of the repaired muscles [54, 55]. EAM promotes formation of large diameter fibrils and demonstrates the greatest cellular response to injury [48]. There are many different EAM regimens with some using a hinged dorsal blocking splint to assist with wrist synergistic motion whereas others use place and hold or active flexion [56, 57]. A well-known protocol is that by Gratton [58] who combined the Belfast and Sheffield practices [54]. The protocol is as follows:

• At postoperative day two to five, a thermoplastic dorsal blocking splint is fashioned with the wrist positioned in 20° of flexion and the MCP joints in 80° of flexion with the IP joints in full extension. If the patient has significant oedema, the active ROM exercises are delayed until day five. Oedema is treated with compression and elevation.

• If oedema is not significant, exercises begin with passive flexion of the digits with active extension to the constraints of the splint.

**9. Conclusions**

programme.

cessful primary repair.

Justin Yousef\* and Sarah Anthony

\*Address all correspondence to: justin.yousef@gmail.com

Lippincott: Williams & Wilkins; 2011

of Hand Surgery. 1999;**24**(2):310

**Author details**

Australia

**References**

2012;**3**(6):62

1998;**23**(1):50-52

Flexor tendon injury outcomes are unsurpassed when they are treated at an early stage. Good surgical technique is vital in to avoid rupture or adhesions. However, of equal importance is the preparation of the patient to expect an individualised long and complex rehabilitation

Flexor Tendon Injuries

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Secondary reconstruction is complex and rarely results in the same level of function as a suc-

Department of Plastic and Reconstructive Surgery, The Northern Hospital, Melbourne,

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[4] Zafonte B, Rendulic D, Szabo RM. Flexor pulley system: Anatomy, injury, and manage-

[5] Mitsionis G, Bastidas JA, Grewal R, Pfaeffle HJ, Fischer KJ, Tomaino MM. Feasibility of partial A2 and A4 pulley excision: Effect on finger flexor tendon biomechanics. The Journal

[6] Tomaino M, Mitsionis G, Basitidas J, Grewal R, Pfaeffle J. The effect of partial excision of the A2 and A4 pulleys on the biomechanics of finger flexion. The Journal of Hand Surgery.

[7] Myer C, Fowler JR. Flexor tendon repair: Healing, biomechanics, and suture configura-

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None of the EAM protocols should be followed exactly- the surgeons and therapist must individualise treatment to patient circumstances [39, 59]. For example, advancement to the next phase of a protocol may need to be quicker or slower based on the level of oedema, passive versus active flexion lags, and adhesion formation [59]. Interestingly, the initiation of rehabilitation is a critical factor in successfully rehabilitating flexor tendon repairs. Initiating therapy by postoperative day five has been shown to decrease the rate of secondary procedures and decrease costs of treatment irrespective of whether or not a passive or active protocol is used [60].
